Fillable Form Ptr-1 - Property Tax Reimbursement Application

Income Worksheet A

Income Worksheet B

2003 Total Income

2004 Total Income

If you were married as of December 31, 2003, you must combine

If you were married as of December 31, 2004, you must combine

your income with your spouse’s income.

a. Social Security Benefits . . . . . . . . ____________________

(including Medicare Part B premiums)

b. Total Pension Income . . . . . . . . . . ____________________

(including IRA and annuity income)

c. Salaries and Wages . . . . . . . . . . . ____________________

d. Bonuses, Commissions & Fees . . ____________________

e. Unemployment Benefits . . . . . . . . ____________________

f. Interest (taxable & exempt) . . . . . ____________________

g. Dividends . . . . . . . . . . . . . . . . . . . ____________________

h. Net Capital Gains . . . . . . . . . . . . . ____________________

i. Net Rental Income . . . . . . . . . . . . ____________________

j. Net Business Income . . . . . . . . . . ____________________

k. Support Payments . . . . . . . . . . . . ____________________

l. Inheritances . . . . . . . . . . . . . . . . . ____________________

m. Royalties . . . . . . . . . . . . . . . . . . . . ____________________

n. Gambling & Lottery Winnings . . . . ____________________

(including New Jersey)

o. All Other Income . . . . . . . . . . . . . ____________________

p. TOTAL . . . . . . . . . . . . . . . . . . . . . ____________________

Was your total 2003 income less than $40,028 if you were single,

Was your total 2004 income less than $40,869 if you were single,

OR less than $49,082 (combined income) if you were married?

OR less than $50,113 (combined income) if you were married?

Yes. Enter the total amount on Line 7 and continue with

Yes. Enter the total amount on Line 8 and continue

Income Worksheet B.

completing the application.

No. STOP. You are not eligible for a property tax

reimbursement.

Proof of Age or Disability Must Be Submitted With Application

Age 65 or Older. If you (or your spouse) indicated at Line 4a that you were 65 or older on December 31, 2003, you must submit proof

of age with your application. Examples of acceptable documentation include copies of the following:

Birth Certificate

Driver’s License

Church Records

Receiving Federal Social Security Disability Benefits. If you (or your spouse) were under 65 and indicated at Lines 4a and 4b that

you were receiving Federal Social Security Disability Benefits on December 31, 2003, and you (or your spouse) continued to receive

benefits through December 31, 2004, you must submit with your application a copy of the Social Security Award Letter indicating that you

(or your spouse) were receiving benefits based on your own social security number. Note: If your marital status is “Married,” the same

person who was receiving disability benefits on December 31, 2003, must still be receiving benefits on December 31, 2004.

Form Ptr-1 - Property Tax Reimbursement Application - 2004 Page 2

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